Insured by Humana Insurance Company or HumanaDental Insurance Company TX HH 8/06

Transcription

1 S U M M A R Y O F B E N E F I T S F O R T E X A S Preferred Provider Organization (PPO) Individual Health Insurance TX HH 8/06 Insured by Humana Insurance Company or HumanaDental Insurance Company

2 Individual Health Insurance Created with you in mind HumanaOne Health Plans The protection you need HumanaOne was created with you in mind self-employed individuals, small business employees and others who are not covered under a group health insurance plan to protect you when you need care and help manage your health care costs. HumanaOne understands that you pay 100 percent of your health care premiums. That s why we offer affordable insurance plans to individuals and families. HumanaOne s Individual Health Plan covers more than just basic health care. You ll receive the same benefits you d expect from a group insurance plan, such as a variety of annual deductible options from which to choose; five million dollars worth of lifetime coverage; and coverage for preventive care, physician and hospital services, and prescription drugs. The Individual Health Plan is a traditional Preferred Provider Organization (PPO) product that pays a percentage for your health expenses once you have met your annual deductible. Some expenses are paid before the deductible and other services may require you to pay a copayment. A copayment does not apply towards your annual deductible or out-of-pocket maximum.

3 flexibility Manage your health insurance coverage and cost. options Choose benefits to enhance your plan. The power of security The coverage you need and more. 3

4 Why choose Peace of mind With HumanaOne, you could have the peace of mind that comes from knowing you are protected from financial hardship that could accompany a major medical event. Ample Coverage Five million dollars in lifetime benefits. Regulated Rates Rates are regulated by the state where policyholders reside. Rate Guarantee Premium rates are guaranteed for the initial 12 months as long as you stay with the same plan and reside in the same area. Portable Plan Benefits HumanaOne provides insurance coverage if you move to another state. Your rate may change based on your ZIP code, but you won t need to reapply for benefits and risk being denied. Greater savings HumanaOne understands that when choosing a health care provider, you also need to think about costs. That s why HumanaOne continues to be committed to saving you money and time. Competitive Rates HumanaOne offers competitive rates, saving you money for the benefits you receive. Negotiated Rates Save over the price typically charged for medical services when you visit an in-network provider. This helps you limit out-of-pocket costs, regardless of your benefits. Smarter Management HumanaOne provides online tools to help you manage your health care dollars more wisely. Doctors find it easier to do business with Humana than any other insurance company, according to a study conducted by Physicians Practice and athenahealth athenahealth. (2006, May 30). PayerView Index ranking of health insurer performance from physicians. Retrieved August 3, 2006, from the World Wide Web:

5 HumanaOne? Your personal Website Get the most out of your plan with MyHumana a password-protected, personal home page available any time, any where. MyHumana offers powerful tools designed to help you manage your medical costs and understand your plan more effectively. Some consumers could save hundreds of dollars by making more informed choices. Use MyHumana to: Review your plan benefits and check claims status. Track your deductible balance and out-of-pocket medical expenses. Reduce your prescription drug costs by researching alternatives. Consult with your physician before changing prescription drugs. Search for an in-network primary care physician or specialist. Research a medical condition. Customer care HumanaOne s commitment to customer care makes it easy for you to choose and use our health insurance with confidence. Convenient Application Process You can apply for a health insurance plan and complementary coverage, such as life and dental insurance, through one convenient application online or telephonically. Customer Service Receive the attention you deserve with a customer support team ready to answer questions about benefits and claims. Claim payments are delivered in a timely and accurate manner. Health Plan Guidance You will receive a health plan guide within days of your approval. This easy to follow guide helps you understand your health plan and use your benefits to the fullest. COMMON INSURANCE TERMS TO KNOW Deductible: The total dollar amount you pay annually before the plan begins to pay for covered expenses. Copayment: The amount you pay whenever you receive medical services or a prescription drug. Coinsurance: Coinsurance is the set percentage of health care costs you pay after you have satisfied your yearly deductible. Preferred Provider Organization (PPO): Humana s network of health care providers contracted to provide services at a discounted rate. In-Network Provider: Doctor, health care facility or other health care professional that is contracted with Humana and offers discounted rates. Out-of-Network Provider: Doctor, health care facility or other health care professional that is not contracted with Humana. 5

6 Options for every lifestyle. You decide with HumanaOne. Choose from the following benefit options to enhance your Individual Health Plan: Zero deductible prescription option Pharmacy benefits begin immediately without having to meet a separate prescription drug deductible. Office visit copayment option* In-network office visits for illness or injury are paid at 100 percent after a copayment. The option does not apply for preventive care services or nonparticipating providers. Four visits per member per year. Maternity benefit* Provides coverage for pregnancy and routine newborn well-baby services. A waiting period applies. * Can vary by state and/or health plan. Prescription drug benefits The Rx4 prescription drug benefit is included with the Individual Health Plan and has a separate $500 deductible. Once you reach the $500 prescription drug deductible per benefit year, you are only responsible for a copayment and the plan pays the remaining cost for drugs filled at a participating pharmacy. Each prescription drug is assigned to one of four levels with a different copayment for each level. A prescription drug will be covered to some degree, no matter which level it is assigned (see the following Summary of Benefits for specific benefit information). Mail-order prescription drugs Save money and time by purchasing prescription drugs through a participating mail-order pharmacy. You are covered for up to a 90-day supply per prescription or refill and a 30-day supply for self-administered injectable drugs. HumanaOne s medical provider networks HumanaOne health plans provide access to Humana s extensive network of doctors, pharmacies and hospitals. So, no matter where you work, live or travel throughout the continental United States, you are covered. Additionally, you have the freedom to see the provider of your choice. You will receive the most savings from your plan when visiting a provider in-network, but you re still covered if you choose to visit an out-of-network provider. Level One Lower-cost generic and some brand-name drugs Level Two Higher-cost generic and some brand-name drugs Level Three Higher-cost, mostly brand-name alternatives to drugs on Level One and Two. Also includes some selfadministered injectable medications. Level Four Highest-cost, including self-administered injectable medications and high technology drugs 6

7 Additional benefit options offered beyond health insurance HumanaOne Dental Insurance* Keep your smile looking healthy with access to more than 80,000 dentist locations. Benefits include coverage for preventive care services, basic and major services, teeth whitening services (not available in Florida) and a discount on orthodontia services. You can keep your dental coverage if you cancel your medical policy or move residences within the United States. * Not available in all states. HumanaOne Term Life Insurance Affordable protection for you and your loved ones. For your security and peace of mind, HumanaOne Term Life Insurance provides coverage amounts from $25,000 to beyond $1 million and premiums are level for 10, 15 or 20 years. Your plan is guaranteed renewable up to age 95 after the initial coverage term. Conveniently apply for HumanaOne Term Life Insurance in conjunction with your health plan application, or at another time. HumanaOne Individual Health Insurance from Humana Inc. Humana Inc., based in Louisville, Kentucky, is one of the nation s largest publicly traded health benefit companies with over 9 million members. Humana delivers health insurance coverage to employer groups, government-sponsored plans and individuals. Humana s experience, nationwide presence and ability to secure cost-savings discounts are shared with HumanaOne members. Eligibility The issue age for insurance through HumanaOne is two months to 63 ½ years. For most states, the maximum age for a dependent child is 25 years if the child is a full-time student and 19 years if the child is not a full-time student. You must be approved through medical underwriting when applying for a HumanaOne individual health plan. In general, you may be eligible if: You are generally in good health; Your height and weight is proportionate for someone of your age and gender; You are not pregnant or expecting a child (including fathers); and If older than age 55, you have had a physical exam within the past two years. 7

8 H u m a n a O n e T E X A S P l a n 4 9, O p t i o n Plan pays for services at PARTICIPATING providers Annual Deductible (1), (2) Single Family Deductible Deductible (3) Annual amount (does not apply to $ 500 $ 1,500 maximum out-of-pocket expense) 1,000 3,000 2,500 5,000 5,000 10,000 Deductible Carryover Maximum Out-of-Pocket Expense Limit (1), (2) Individual (must be satisfied by each covered person) Plan pays for services at NONPARTICIPATING providers Single Family Deductible Deductible (3) $ 1,000 $ 3,000 2,000 6,000 5,000 10,000 10,000 20,000 Covered expenses incurred in the last three months of the calendar year and applied to the deductible will be credited to the next calendar year deductible. $2,000 $8,000 Lifetime Maximum Benefit $5,000,000 per covered person Preventive Care Routine immunizations (birth to age 6) 100% 100% Routine annual physical exam (4), (5) 80% 60% after deductible Routine immunizations (age 6 to age 18) (4), (5) Routine Pap smears (4), (5), (6) PSA (6) Routine Mammograms (6) Colorectal detection screening Routine lab, pathology and X-ray (4), (5) 80% after deductible 60% after deductible Physician Services Office visits (includes diagnostic lab and 80% after deductible 60% after deductible X-ray) Allergy testing, injections and serum Inpatient services Outpatient services (includes surgery) (7) Hospital Services Inpatient care Outpatient surgery facility (7) Outpatient nonsurgical 80% after deductible 60% after deductible Emergency room (including physician visits) 80% after $75 copayment per visit and deductible (copayment waived if admitted) 60% after $75 copayment per visit and deductible (copayment waived if admitted) This document contains a general summary of benefits, exclusions and limitations. Please refer to the policy for the actual terms and conditions that apply. In the event there are discrepancies with the information given in this document, the terms and conditions of the policy will govern. 8

9 H u m a n a O n e T E X A S P l a n 4 9, O p t i o n Prescription Drugs (8) Prescription drug deductible (Covered prescription drugs are assigned to one of four different levels with corresponding copayment amounts.) (2) Benefit for each prescription or refill (up to 30-day supply) Level One - lowest copayment for lowest cost generic and brand-name drugs Level Two - higher copayment for higher cost generic and brand-name drugs Level Three - higher copayment than Level Two for higher cost, mostly brandname drugs that may have generic or therapeutic equivalents in Levels One or Two Level Four - highest copayment for high-technology drugs (certain brandname drugs, biotechnology drugs and self-administered injectable medications) Mail order (90-day supply) Other Medical Services Skilled nursing facility (up to 30 days per calendar year) (9) Home health care (up to 60 visits per calendar year) (9) Durable medical equipment (9) Hospice (9) (10) Complications of pregnancy and sick baby services Transplant services (organ) (9) Mental Health (includes mental disorders, alcohol and chemical dependence) (4) Inpatient and Outpatient care (Combined $2,500 per calendar year maximum. Outpatient care not to exceed $500 of the $2,500 calendar year maximum.) Plan pays for services at PARTICIPATING providers $500 prescription drug deductible per individual 100% after: 70% after: $10 copayment after prescription drug deductible $30 copayment after prescription drug deductible $50 copayment after prescription drug deductible 25% copayment after prescription deductible up to $2,500 maximum out-of-pocket per calendar year 100% after three times the retail copayment Plan pays for services at NONPARTICIPATING providers $500 prescription drug deductible per individual $10 copayment after prescription drug deductible $30 copayment after prescription drug deductible $50 copayment after prescription drug deductible 25% copayment after prescription deductible up to $2,500 maximum out-of-pocket per calendar year 70% after three times the retail copayment 80% after deductible 60% after deductible 80% after deductible (when services are performed at a National Transplant Network provider) 60% after deductible (subject to separate out-of-pocket maximum of $35,000 per calendar year) 75% after deductible 50% after deductible 9

10 H u m a n a O n e T E X A S P l a n 4 9, O p t i o n Optional Benefits (11) Prescription drug, no deductible Maternity including routine newborn care (waiting period applies) (2), (4) Office visit copayment option (includes diagnostic tests, lab and X-rays, paid at 100% up to $100 per calendar year. Does not apply to preventive/routine care) (2), (12) Optional Dental benefits (with teeth whitening) (13) You can choose any dentist, but you can save up to 30 percent on out-of-pocket costs when you visit one of the more than 75,000 dentist locations in the PPO network. You can find a dentist by visiting Preventive services plan pays 100% no deductible Oral examinations Routine cleanings X-rays Sealants Topical fluoride treatment Basic services plan pays 50% after deductible Emergency exams and palliative care for pain relief Thumb sucking and harmful habit appliances Space maintainers Amalgam, composite fillings Oral surgery Extractions (routine) Non-cast stainless steel crowns Partial or complete denture repairs/adjustments Teeth whitening services plan pays 50% after deductible $200 lifetime maximum Plan pays for services at PARTICIPATING providers Major services plan pays 50% after deductible Endodontics (root canals) Periodontics Crowns Inlays and onlays Partial or complete dentures Denture relines/rebases Removable or fixed bridgework Orthodontia discount Members can receive up to 20 percent discount if they visit an orthodontist from the HumanaDental PPO Network and ask for the discount. Annual Deductible $50 individual $150 family Annual maximum benefit $1,000 Plan pays for services at NONPARTICIPATING providers Under this option, no deductible is required to be met before plan benefits are payable. 75% after $500 maternity deductible 50% after $1,000 maternity deductible 100% after $25 copayment for a Level One provider and $40 copayment for a Level Two provider limited to four combined visits (Level One and Level Two providers) per calendar year. After four visits, plan pays 80% after deductible 70% after deductible for first four visits; 60% after deductible thereafter 10

11 To be covered, expenses must be medically necessary and specified as covered. Please see your policy for more information on medical necessity and other specific plan benefits. (1) When you obtain care from nonparticipating providers: 50 percent of your payment toward the deductible is credited to the deductible for participating providers. 50 percent of your out-of-pocket costs are credited to the out-of-pocket maximum for participating providers. Once you meet your deductible and out-of-pocket expense limits, the plan pays 100 percent for covered services. (2) Copayments do not apply to the deductible or out-of-pocket maximum. The medical out-of-pocket maximum does not apply to transplant services from nonparticipating providers, Payments - Participating providers agree to accept amounts negotiated with Humana as payment in full. The member is responsible for any required deductible, coinsurance, or other copayments. Plan benefits paid to nonparticipating providers are based on maximum allowable fees, as defined in your policy. Nonparticipating providers may balance bill you for charges in excess of the maximum allowable fee. prescription drugs, mental health services or maternity, if the optional maternity benefit is selected. (3) At least two family members must meet their individual deductibles. (4) Benefit payable after 30-day waiting period for mental health and maternity, 90-day waiting period for preventive care. (5) $300 of covered expenses per person per calendar year, subject to applicable coinsurance. (6) Age and/or frequency limits apply. (7) Outpatient benefits payable after 90-day waiting period for nonemergency removal of tonsils and/or adenoids, and 180-day waiting period for nonemergency surgical treatment for bunions, varicose veins, hemorrhoids or hernia (does not include strangulated or incarcerated hernia). (8) If a nonparticipating pharmacy is used you must pay 100 percent of the actual charges and file a claim with Humana for reimbursement. You will be responsible for charges in excess of the maximum allowable fee in addition to any applicable deductible, coinsurance, or copayment. Additionally, any amount you pay the provider in excess of the maximum allowable fee will not apply to your out-of-pocket limit or deductible. Participating Level One and Level Two and other providers in Humana s networks are not the agents, (9) Prior authorization required in order to be eligible for these benefits. (10) Counseling for hospice patient and immediate family is limited to 15 visits per family per lifetime. Medical Social Services limited to $100 per family per lifetime. (11) These benefits are optional and can be added to your plan for an additional cost. Optional benefits may not be available in all areas. (12) This benefit does not cover MRI, CAT, EEG, EKG, ECG, cardiac catheterization or pulmonary function studies. Level One providers include family practitioner, general practitioner, pediatrician or internist; Level Two providers contain any other participating physician. Please contact Customer Service for details. (13) This is not a complete disclosure of plan qualifications and limitations. Waiting periods apply: six months on basic services and teeth whitening, 12 months on major services. Please review the specific Dental Limitations and Exclusions before applying for coverage. employees or partners of Humana or any of its affiliates or subsidiaries. They are independent contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgment or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. 11

12 Medical Limitations and Exclusions This is an outline of the limitations and exclusions for the HumanaOne Individual Health Plan. It is designed for convenient reference. Consult the policy for a complete list of limitations and exclusions. PRE-EXISTING CONDITIONS A pre-existing condition is a sickness or injury which was diagnosed or treated, or which produced signs or symptoms that would cause an ordinary prudent person to seek treatment, during the five-year period before the covered person s effective date of coverage. Benefits for pre-existing conditions are not payable until the covered person s coverage has been in force for 12 consecutive months with us. We will waive the pre-existing conditions limitation for those conditions disclosed on the application provided benefits relating to those conditions are not excluded. Conditions specifically excluded by rider are never covered. OTHER EXPENSES NOT COVERED Unless stated otherwise no benefits are payable for expenses arising from: 1. Services not medically necessary or which are experimental, investigational or for research purposes. 2. Services not authorized or prescribed by a health care practitioner or for which no charge is made. 3. Services while confined in a hospital or other facility owned or operated by the United States government, provided by a person who ordinarily resides in the covered person s home or who is a family member, or that are performed in association with a service that is not covered under the policy. 4. Charges in excess of the maximum allowable fee or which exceed any policy benefit maximum. 5. Expenses incurred before the effective date or after the date coverage terminated. 6. Cosmetic procedures and any related complications except as stated in the policy. 7. Custodial or maintenance care. 8. Any drug, medicine or device which is not FDA approved. 9. Medications, drugs or hormones to stimulate growth. 10. Legend drugs not recommended or deemed necessary by a health care practitioner or drugs prescribed for a noncovered injury or sickness. 11. Drugs prescribed for intended use other than for indications approved by the FDA or recognized off-label indications through peerreviewed medical literature, experimental or investigational use drugs. 12. Over the counter drugs (except insulin) or drugs available in prescription strength without a prescription. 13. Drugs used in treatment of nail fungus. 14. Prescription refills exceeding the number specified by the health care practitioner or dispensed more than one year from the date of the original order. 15. Vitamins, dietary products and any other nonprescription supplements. 16. Infertility services. 17. Pregnancy and well-baby expenses. 18. Elective medical or surgical procedures; abortion; gender change or sexual dysfunction. 19. Vision therapy; all types of refractive keratoplasties or any other procedures, treatments or devices for refractive correction; eyeglasses; contact lenses; hearing aids; dental exams. 20. Hearing exams (except for children from birth through 24 months of age); eye exams; routine physical exams for occupation, employment, school, travel, purchase of insurance or premarital tests. 21. Dental services (except for dental injury), appliances or supplies. 22. War or any act of war, whether declared or not; commission or attempt to commit a civil or criminal battery or felony. 23. Standby physician or assistant surgeon, unless medically necessary; private duty nursing; communication or travel time; lodging or transportation, except as stated in the policy. 24. Obesity except for morbid obesity. 25. Nicotine habit or addiction; educational or vocation therapy, services and schools; light treatment for Seasonal Affective Disorder (S.A.D.); alternative medicine; marital counseling; genetic testing, counseling or services; sleep therapy or services rendered in a premenstrual syndrome clinic or holistic medicine clinic. 26. Foot care services except as stated in the policy. 27. Charges for nonmedical purposes or used for environmental control or enhancement (whether or not prescribed by a health care practitioner). 28. Health clubs or health spas, aerobic and strength conditioning, work hardening programs and related material and products for these programs; personal computers and related or similar equipment; communication devices other than due to surgical removal of the larynx or permanent lack of function of the larynx. 29. Hair prosthesis, hair transplants or implants and wigs. 30. Temporomandibular joint disorder, craniomaxillary disorder, craniomandibular disorders, and any treatment for jaw, joint or head and neck neuromuscular disorder. 31. Injury or sickness arising out of or in the course of any occupation, employment or activity for compensation, profit or gain, whether or not benefits are available under Workers Compensation. This exclusion does not apply to a covered person qualifying as a sole proprietor, officer or partner under state law, and such benefits are not covered under any Workers Compensation plan, provided the covered person is not covered under a Workers Compensation plan. 32. Inpatient services when in an observation status or when the stay is due to behavioral, social maladjustment, lack of discipline or other antisocial actions not a result of a mental disorder. 33. Attempted suicide or intentionally self-inflicted injury, whether sane or insane. 34. Organ transplants not approved based on established criteria or investigational, experimental or for research purposes. 35. Charges incurred for a hospital stay beginning on a Friday or Saturday unless due to emergency care or surgery is performed on the day admitted. 12

13 D e n t a l L i m i t a t i o n s a n d E x c l u s i o n s This is an outline of the limitations and exclusions for the HumanaOne Individual Dental Plan. It is designed for convenient reference. Consult the policy for a complete list of limitations and exclusions. Unless stated otherwise, no benefits are payable for expenses arising from: 1. The course of any occupation or employment for compensation, profit or gain, for which benefits are provided or payable under any Workers Compensation or Occupational Disease Act or Law; or where such coverage was available, regardless of whether the coverage was actually applied for. 2. Services and supplies for which no charge is made, or for which the covered person would not be required to pay in the absence of insurance. 3. Services furnished by or payable under any plan or law through any Government or any political subdivision. 4. Services furnished by any hospital or institution owned or operated by the United States Government. 5. War or any act of war, whether declared or not; or any act of international armed conflict or any conflict involving armed forces of any international authority. 6. Completion of forms or failure to keep an appointment with a dentist. 7. Cosmetic dentistry, except as stated in the policy. 8. Any service related to altering vertical dimension; restoration or maintenance of occlusion; splinting teeth; replacing tooth structures lost as a result of abrasion, attrition or erosion; or bite registration or bite analysis. 9. Bone grafts, regeneration, augmentation or preservative procedures in edentulous sites. 10. Implants, including any crowns or prosthetic device attached to it; precision or semi-precision attachments; overdentures and any endodontic treatment associated with it; or other customized attachments. 11. Infection control. 12. Fees for treatment by other than a dentist, except as stated in the policy. 13. Any hospital, surgical or treatment facility, or for services of an anesthesiologist or anesthetist. 14. Prescription drugs or pre-medications, whether dispensed or prescribed. 15. Any service not listed as a covered expense. 16. Any service not considered a dental necessity, does not offer a favorable prognosis, does not have uniform professional endorsement, or is experimental or investigational in nature. 17. Expenses incurred prior to the effective date or after the date coverage is terminated, subject to the grace period, except for any extension of benefits. 18. Services provided by a person who ordinarily resides in the covered person s home or who is a family member. 19. Charges in excess of the reimbursement limit for the service or supply. 20. Treatment as a result of an intentionally self-inflicted injury or bodily illness, while sane or insane. 21. Local anesthetics, irrigation, nitrous oxide, bases, pulp caps, temporary dental services, study models, treatment plans, occlusal adjustments, or tissue preparation associated with impression or placement of a restoration, charged as a separate service. 22. Repair and replacement of orthodontic appliances. 13

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16 This document contains a general summary of benefits, exclusions and limitations. Please refer to the policy for the actual terms and conditions that apply. In the event there are discrepancies with the information give in this document, terms and conditions of the policy will govern. Policy Number: TX COVER 8/2002, et al TX HD et al Insured by Humana Insurance Company or HumanaDental Insurance Company TX HH